title: Modifications, classification, and outcomes of elephant-trunk procedures.
abstract: BACKGROUND
  There are a variety of modified elephant-trunk methods, including use of endovascular stents. Our objectives were to classify these modifications, compare outcomes between the classic anastomotic site and these alternatives, and investigate time to second-stage elephant-trunk completion.
  
  
  METHODS
  From May 1992 to January 2011, 526 patients underwent a first-stage elephant-trunk procedure and were the subject of analysis.
  
  
  RESULTS
  Distal aortic anastomosis was located before the brachiocephalic artery in 6 patients (1.1%), between brachiocephalic and left common carotid artery (LCCA) in 1 (0.19%), between LCCA and left subclavian artery (LSCA) in 154 (29%), and beyond the LSCA (classic) in 365 (69%). Stroke occurred in 8% (n = 42) overall, 10% (n = 16) in the LCCA-LSCA group, and 6.8% (n = 25) in the classic group. Risk factors were older age and acute dissection. Thirty-day mortality was 7.6% (n = 40) and was similar for LCCA-LSCA (9.7%) and classic sites (6.3%; p = 0.7); risk factors included older age, smaller body surface area, and end-organ dysfunction. Likelihood of death before second-stage elephant trunk at 1, 4, and 8 years after operation was 16%, 22%, and 27%, respectively. The larger the distal aorta, the more likely was second-stage completion (p < 0.0001); when greater than 6 cm, 80% had second-stage completion.
  
  
  CONCLUSIONS
  The elephant-trunk operation is safe for a broad population, including when anastomotic sites are other than beyond the LSCA. Without second-stage completion, patient mortality increases markedly after 4 years.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44915, USA. svenssl@ccf.org
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.forename: Gregory D
authors.initials: GD
authors.lastname: Rushing
authors.forename: Edgardo Sepulveda
authors.initials: ES
authors.lastname: Valenzuela
authors.forename: Aldo E
authors.initials: AE
authors.lastname: Rafael
authors.forename: Lillian H
authors.initials: LH
authors.lastname: Batizy
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.forename: Bruce W
authors.initials: BW
authors.lastname: Lytle
mesh_terms: D000714:Anastomosis, Surgical / Q000379:methods; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery; D001018:Aortic Diseases / Q000401:mortality / Q000601:surgery*; D017536:Carotid Artery, Common; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D015607:Stents; D013348:Subclavian Artery; D013997:Time Factors; D014656:Vascular Surgical Procedures / Q000379:methods
keywords: 26